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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700535
Report Date: 08/29/2022
Date Signed: 08/29/2022 02:32:38 PM


Document Has Been Signed on 08/29/2022 02:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:SPLENDOR OF CARMICHAEL AT PALM, THEFACILITY NUMBER:
342700535
ADMINISTRATOR:FOGGY, BRUCEFACILITY TYPE:
740
ADDRESS:2839 CALIFORNIA AVETELEPHONE:
(916) 514-9421
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
08/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Maria Williams, Administrator TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA met with Maria Williams, Administrator, and Eugene Bruce,caregiver, and explained purpose of inspection. Bruce Foggy, Administrator, arrived at the facility at approximately 1:45 pm. LPA observed (2) residents in the common area watching television and (4) residents to be in their rooms at the start of the inspection. Currently, there are (2) residents on hospice. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (3). Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. LPA was screened per Covid-19 precautionary measures upon entering the facility. and the following Personal Protective Equipment (PPE) was worn: surgical mask

LPA and Administrator toured the interior and exterior of the facility including the common areas, resident bedrooms (6), resident bathrooms (6), kitchen, staff room (2) and laundry area. LPA observed the facility to be clean, in good repair and odor-free. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters posted. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food and locked sharps in the kitchen. LPA observed toxins and medications to be secured in the laundry room and in a separate cabinet. LPA observed the inside temperature to be 76*F. LPA observed (2) unlocked outside gates from the inside and a pool that is gated with a key lock. Discussed vaccination status of residents/staff, eligibility for boosters and visitation protocols. All staff are cleared/associated. Administrator certificate # 6003533740- exp 8/26/2023 for Maria A, Williams. Bruce Foggy, Administrator to post the current copy of Administrator certificate # 6046548740- exp 12/11/2022. Administrator, Maria, stated that all staff training is current. Notice is still posted in common area of facility. LPA observed both fire doors to be kept open by an approved fire device. LPA provided some sanitizers, wipes gloves and gowns from Regional Office supply during today's inspection. LPA requested an updated copy of LIC500, LIC308 and of the current liability insurance be provided to the CCLD by 9/7/22 and a copy of the Infection Control Plan if not already sent in. Updated staff roster obtained.
There are no deficiencies issued during today's inspection. Exit interview. Copy of report provided during today's inspection.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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